Healthcare Provider Details

I. General information

NPI: 1780428763
Provider Name (Legal Business Name): GLADYS TIH OWUOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13045 W PORT ROYALE LN
EL MIRAGE AZ
85335-3428
US

IV. Provider business mailing address

13524 W READE AVE
LITCHFIELD PARK AZ
85340-4019
US

V. Phone/Fax

Practice location:
  • Phone: 602-592-5954
  • Fax:
Mailing address:
  • Phone: 602-592-5954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL12476
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: